Psychometric properties of the quality nursing care scale-turkish version: a methodological study

Aim To analyze the psychometric properties of the Quality Nursing Care Scale in Turkish Language. Background The quality of health services and nursing care effectively improves safe patient outcomes and reduces costs in healthcare organizations. There is a need for valid and reliable tools in order to use for evaluating the quality of nursing care. Methods The methodological and cross-sectional study included 225 nurses working in a research and training hospital. Content validity, construct validity, item analysis, and internal consistency analysis were used. Results The content validity index of the scale was 0.96. The item-total score correlation values of the items were 0.72 and higher. The factor loads of the items ranged from 0.42 to 0.90. Different from the original scale, Turkish form consisted of three sub-dimensions. The fit indices were acceptable or very good. The Cronbach’s alpha internal consistency coefficient was 0.99. Conclusion The Quality Nursing Care Scale was valid and reliable with its three-factor structure in Turkish Language. It may be used for measuring the quality of care in the aspects of nurses.


Background
Today, hospitals have focused on improving care services to meet consumers' expectations [1,2]. The World Health Organization (WHO) reports that approximately 15% of the total deaths (5.7-8.4 million deaths per year) in lowand middle-income countries are due to poor quality care. According to the WHO, quality of care is related to whether the health services provided to individuals and society achieve the desired health outcomes. Thus, health services must be delivered safely, effectively, timely, and efficiently and be equitable and people-centered [3].
Care is at the center of nursing knowledge, skills, and practice. The effectiveness of the care provided plays a role in patient treatment compliance. Improving a healthy individual's health or restoring a sick individual's health is possible through effective nursing care. Therefore, individuals' quality of life can be enhanced through care practices. The hospitalization duration for patients receiving qualified nursing care is also shortened [4]. Nurses are the most critical human resource in providing quality healthcare [5][6][7]. Quality nursing care is one of the factors that can increase patient satisfaction and positively affect patients' recovery processes. In addition, quality nursing care is highly effective in achieving targeted patient outcomes, protecting patients from possible dangers, preventing undesirable consequences, and ensuring patient safety [2,8,9].
Patients and their relatives, hospital administrators, and nurses who provide services may assess the quality of nursing care in their aspects. When evaluating nursing care, patients and relatives mainly focus on their communication with the nurses and whether they can get answers to the questions they ask the nurses. Hospital or nursing managers generally focus on efficiency and cost-effectiveness when evaluating the quality of care. This shows that participants who take on different roles have different knowledge, opinions, and values. Each stakeholder assesses the quality of care in line with their knowledge, belief, and value. Therefore, nurses' evaluations of the care they provide are critical in improving and developing the quality of nursing services [1,10].
Nurses are frontline healthcare professionals who identify, plan, and evaluate patients' needs, advocate for patients, administer medications and treatments and ensure their comfort [3,11]. It is also essential for psychiatric and pediatric clinics, where patients may not evaluate the quality of their care sufficiently in their aspects. Also, it is challenging for patients and other service recipients to evaluate the technical competencies, knowledge levels, and skills of care professionals [12,13].
In the literature, limited studies have evaluated the adequacy of nurses' nursing care [11,14,15]. In addition, many published articles have assessed the quality of nursing care from the patient's perspective [16][17][18]. However, Lynn et al. [14] stated that evaluating the quality of patient care would be incomplete without considering nurses' perspectives. To provide quality care, nurses must be sure of the care provided before all other actors. It allows for developing action plans to measure the quality of care perceived by nurses, strengthen trust in care, and identify potential areas for improvement. It can also help nurses better understand patients' real needs and develop strategies for care [19]. Thus, this study aimed to investigate the psychometrics of the Quality Nursing Care Scale among nurses in the Turkish Language.

Aim
This study aimed to evaluate the psychometrics of the Quality Nursing Care Scale in Turkish.

Study design, setting and sample
This was a methodological and cross-sectional study conducted at a training and research hospital. All nurses working in the hospital's inpatient wards were included in the study. The study sample consisted of 225 nurses accepted to participate in the study. The mean age of the participant nurses was 33.81 (SD = 7.70) years. Nurses' professional and unit experiences were 8.95 (6.94) and 4.29 (4.37) years, respectively. Among the nurses, 86.7% were women, 61.8% were married, and 59.1% were undergraduates: they primarily were working at surgical units (40.0%), both day and night shifts (78.2%). Most of the nurses were working 46 or more hours weekly (73.8%) and caring for 11 or more patients in each change. Also, 66.2% of them were working evening and night shifts six or more times in a month (Table 1).

Procedure
The study followed the required scale adaptation steps according to the International Test Commission and Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines [20][21][22]. Translating the items and measuring the content validity was the first step. Secondly, item-total score correlations of the items were calculated. Then construct validity was tested. Lastly, the internal consistency of the scale was analyzed.

Data collection instruments
Research data were collected online (Google Forms) between September and November 2021. The online surveys were sent online to the nurses working in the institution. They were asked to fill out the forms. Only those who filled out the informed consent form could access the survey, and only the researchers could access the results.
The literature recommends reaching out to individuals 5-10 times the number of items in reliability and validity studies [23]. Since the number of items in the scale to be validated and tested for reliability was 38, researchers aimed at reaching a sample of at least 190 people. The study sample consisted of 225 nurses working at the time of the study. The study data were collected using a questionnaire containing questions to determine personal and professional characteristics and the Turkish version of the Quality Nursing Care Scale.

Information form
It was a form consisting of 18 questions that sought data on the age, gender, marital status, and education level of the nurses participating in the research, the unit they worked in, their working style, their working hours as a nurse, their monthly duty hours, their perception of income, their satisfaction with the institution, unit, working conditions, and salary they received.

Turkish version of quality nursing care scale
The Quality Nursing Care Scale (QNC) is a 5-point Likert-type tool developed by Liu et al. [10]. The scale consisted of six sub-dimensions and 38 items in its original form. The sub-dimensions were entitled Physical environment (six things), Staff characteristic (eight items), Precondition (seven items), Task-orientated activities (six items), Human-orientated activities (five items), and Patient outcomes (six things). The internal consistency coefficient of the scale was 0.96. The answer categories were graded between "strongly agree" (5) and "strongly disagree" (1). High scores indicate higher quality nursing care, and low scores indicate lower quality nursing care.

Ethical considerations
The researchers got permission from the original work's owner to adapt the tool into Turkish. The original scale's author also confirmed that the scale had not been previously adapted to Turkish. Approval of a university hospital's Clinical Research Ethics Committee, dated 05.05.2021 and numbered 98, was obtained. Before data collection, formal written permission was obtained from the hospital administration. Only nurses who agreed to participate in the study and filled out the online informed consent form were included.

Statistical analysis
Data were analyzed via Jamovi, an R-based open statistical software [24]. First, the Davis technique was used to analyze the content and content validity in the study. Second, Pearson correlation analysis was used for item analysis. Third, Kaiser-Meyer-Olkin and Bartlett's tests were used to evaluate sample adequacy. Fourth, exploratory factor analysis was used to determine the construct of the Turkish version. Extraction model was principal axis factoring and rotation method was direct oblimin. Confirmatory factor analysis confirmed the new structure. Finally, Cronbach's alpha internal consistency coefficient was calculated. The accepted significance level was 0.05 for a 95% confidence interval.

Calculation of the content validity index
The Turkish version of the scale was presented to 13 nursing management and internal medicine nursing specialists. As a result of the analysis using the Davis technique, the items' content validity ratios (CVR) ranged from 0.85-1. Therefore, the content validity index of the scale was 0.96 after the content validity rate of each item was summed and divided by the total number of items obtained. The Turkish version was then translated into English by two academicians, one a medical doctor and the other a nurse with a Ph.D.
Performing item-total score correlation analyzes to reveal the compatibility between the items Correlation values obtained from item-total correlation analyses with 38 items regarding the Turkish version of the QNC are shown in Table 2. As a result of the investigation, the item-total score correlation coefficients of the items differed between r = 0.72 and 0.92.

Factor analysis to reveal construct validity
The KMO value was high at 0.975, and Bartlett's test was significant at the < 0.001 level. Then, confirmatory factor analysis was performed first. However, the × 2/df value was 9.82 for the six factored structures. Then an explanatory factor analysis was made to understand the new structure in the Turkish language. The results showed that the factor loads of the items ranged from 0.42 to 0.93. Three subscales explaining 80.806% of the total variance were revealed. First, items 4, 5, 6, 7, 8, 9, and 10 were cross loaded to factors 1 and 2. Next, items 24, 26, and 27 crosses loaded in Factor I and 3. However, the differences in the factor load values of the same items in different factors were over 0.300. Therefore, those items remained in the factors that got higher factor loads. Then confirmatory factors analysis was repeated for the new structure, and the × 2/df value was calculated as 3.85 ( Table 3). The Comparative Fit Index, Standardized Root Mean Square Residual and the Root Mean Square Error of Approximation indices were 0.90, 0.041, and 0.011, respectively (Fig. 1).

Determination of scale internal consistency coefficient for reliability analysis
Cronbach's alpha coefficient of the Turkish version of the Scale was 0.99. The same coefficient for the first df 626 Acceptable value for x 2 /df < 5 Good value x 2 /df < 2 Fig. 1 Path diagram of confirmatory factor analysis subdimension was 0.95, and there were 0.99 for the second and third subdimensions (Table 4).

Discussion
A limited number of measurement tools evaluating nursing care quality requires the development or adaptation of valid and reliable tools assessing the quality of nursing care. Unfortunately, only two measurement tools have been conducted on this subject. One of them is the Caring Behaviors Inventory-24 [25]. The scale was designed to evaluate the nursing care process/quality. Another scale was developed by Leinonen et al. to assess the perceptions of patients' quality of perioperative care [26]. Lennon et al. [27] made minor changes to the items in the scale so that they could be applied to nurses and patients. This study aims to perform psychometrics of Liu et al. 's The Quality of Nursing Care Scale, which consists of 38-item and evaluates the quality of nursing care in the aspect of nurses [10].
Evaluating the quality of care, nurses provide data that will help prevent errors, minimize possible harm to patients, and identify risky situations. At this stage, the validity and reliability of the Turkish version of the QNC are discussed under the headings of language validity, content validity, item-total score correlation analysis, construct validity, and internal consistency reliability.

Language validity
Since the translated items might not mean the same in the adapted language [23,28], experts were asked to evaluate the restated items in terms of meaning. Minor revisions were made considering the experts' recommendations to clarify their meanings in Turkish. For example, wording arrangements were made for Item 5 (I provide a quiet ward environment for patients staying in the hospital), Item 14 (I work well with my team [other nurses and healthcare providers]), Item 16 (I master the clinical, technical operations to meet the needs of nursing care), Item 20 (I can manage drugs well), and Item 21 (I intend to help patients whenever the help is needed). Then, two academicians who knew both languages backtranslated the items into English.

Content validity
Davis technique, a frequently used method developed by a nurse researcher, was used for the content validity analysis [29]. The original and Turkish items were presented to the experts and asked to compare based on their meanings and grammatical structure. It was observed that the experts mainly assessed the Turkish items in the scale as "quite appropriate. " The lowest CVR value was 0.80, an acceptable value in the literature [29,30].

Evaluation of correlations between items
This study evaluated the compatibility of 38 items using item-total score correlations. It was seen that the correlation, or coherence, of each item of the scale with the whole scale.

Examination of construct validity
Although it is recommended that the scale's construct validity be evaluated using confirmatory factor analysis for adaptation studies [31], this study used explanatory factor analysis because the original model did not fit in Turkish based on the confirmatory factor analysis results. Since the literature indicated that the scale's construct would not have the same structure in the local context [23,32], the authors decided to perform a new explanatory factor analysis to explore the system in Turkish. Unlike in the original study, the items were distributed into three subscales instead of six (Table 5). Only the Physical environment and Patient outcomes subscales remained the same. Staff characteristic, Precondition, Task-orientated activities, and Human-orientated activities subscales merged into one subdomain in the Turkish context. When the statements were evaluated carefully, the meanings of the statements were precise in Turkish. However, it was assessed that nurses perceived the statements under one subdomain because they perceived all items under Staff characteristic, Precondition,  Task-orientated activities, and Human-orientated activities subscales related. The authors evaluated that those items differed from others because they were mainly associated with primary nursing roles and tasks. For example, the items in the physical environment subdomain might also be related to the other staff and the hospital environment. Patient outcomes were related to the customers' perspective. However, the items that emerged with one subdomain were directly associated with nurses and nursing. Therefore, the authors named that domain "Nursing."

Internal consistency analysis
The Cronbach's alpha internal consistency test, the most commonly used test to assess the internal consistency of Likert scales, evaluated the reliability of the subscales and scale in Turkish [33]. Although the acceptable Cronbach's alpha coefficient level has varied in previous reports, the commonly recommended threshold value is 0.70 [34][35][36]. The Cronbach's alpha coefficients of the scale and subscales in Turkish form were relatively high and indicated high reliability. The coefficients were also higher than the original work's values.

Limitations
Although we planned to reach out more participants and to perform confirmatory and exploratory factor analysis on different sample groups in study setting, we could not reach out enough number of nurses because of the huge working conditions during COVID-19 Pandemic.

Conclusions
The study concluded that Turkish version of the QNC was a valid and reliable tool among clinical nurses. The psychometrics characteristics of the form revealed that the tool had required qualifications and could be used to evaluate nurses' perceptions of the quality of nursing care in studies conducted in Turkey. Nurse managers can identify institutional-level problems using the results of nurses' evaluation of the quality of care provided and develop quality improvement programs in this direction. Owing to these practical strategies, cost savings and optimal maintenance can be achieved. In addition, researchers studying topics related to the subject can benefit from the scale in evaluating nursing care from the nurses' perspective. Since stability was not evaluated in this study, further studies may measure it.